I. Definitions and background

Factitious disorder

Factitious disorder is a condition in which a patient falsifies symptoms of illness for the purpose of assuming the sick role. Factitious disorder is a psychiatric diagnosis, and according to the American Psychiatric Association Diagnostic and Statistical Manual of Mental Disorders, 4th Edition (DSM-IV-TR), patients must meet the following criteria:

Intentional production or feigning of physical or psychological signs or symptoms

Motivation for the behavior is to assume the sick role

Absence of external incentives for the behavior

Numerous descriptions of factitious disorders have been reported in the literature. DSM-IV-TR classifies factitious disorders on the basis of the presenting symptoms and recognizes four types:

There are several ways by which patients might feign illness. Patients may lie about the presence of subjective symptoms like abdominal pain or hallucinations, or fabricate an entire history, such as the circumstances leading to the development of post-traumatic stress disorder or headaches. Patients may also falsify objective signs by tampering with equipment or laboratory specimens, such as by manipulating a thermometer to produce evidence of a fever, or by adding blood to a urine sample to simulate hematuria.

Some patients with factitious disorder will exaggerate real symptoms, such as by claiming that mild musculoskeletal chest discomfort is crushing chest pain. Further, patients may intentionally not comply with medical therapy in order to aggravate a pre-existing condition, such as by deliberately not taking prescribed insulin in order to exacerbate hyperglycemia. Finally, a significant subset of patients will self-inflict illness, such as by ingesting excess thyroid hormone or introducing bacteria into wounds.

Other examples of factitious illnesses that may be encountered in the hospital setting include self-induced hypoglycemia, gastrointestinal bleeding, fever of unknown origin, or diarrhea; however, the possibilities are unlimited.

The term factitious disorder is often used interchangeably with the termMunchausen syndrome, which draws its name from a real-life German cavalry officer who would tell whimsical stories about his adventures. Munchausen syndrome is, in fact, a subtype of factitious disorder which is chronic and severe. These patients typically have a history of multiple hospitalizations at different hospitals, often in different cities, with dramatic and even life-threatening presentations requiring invasive procedures. Patients with Munchausen syndrome often display aggressive and antisocial behaviors. They lie pathologically, are disruptive with staff, and may leave against medical advice when confronted.

Factitious disorder by proxy

Also known as Munchausen syndrome by proxy, factitious disorder by proxy is a subtype of factitious disorder in which a caregiver fabricates illness in an individual who is under his or her care. This scenario is seen most commonly with mothers who intentionally cause illness in their child due to their own need to assume the sick role.

Hospitalists must understand the varying presentations and risk factors for factitious illness for several reasons. First, diagnosis often requires a high index of suspicion, so providers must consider factitious disorder when formulating their differential diagnosis. Further, the public health impact of factitious disorders can be significant, as patients with factitious illness utilize healthcare resources unnecessarily and often have associated disability. Lastly, patients admitted with factitious disorders can present challenges with regard to interpersonal communication, so it is important for providers to understand the motivation for the patients' behaviors and to have specific strategies to evaluate and to treat these patients.

Factitious disorders must be distinguished from other conditions that may present in a similar fashion.Malingering is a condition where a patient feigns illness for the purpose of external incentives, such as monetary gain or avoiding work or legal responsibility. Malingering is not a psychiatric diagnosis, and may be easier to identify than factitious disorder as the motivation for feigning illness in malingering is usually much more clear.

Somatoform disorders

Somatoform disorders' conditions are where signs and symptoms of illness are involuntarily produced, yet cannot be explained by a medical condition, substance use, or another psychiatric disorder. DSM-IV-TR specifies seven types of somatoform disorders:

Somatization disorder - patients present with a longstanding history of multiple physical complaints beginning in early adulthood and characterized by the presence of at least four pain symptoms, two gastrointestinal symptoms, one sexual symptom, and one pseudoneurological symptom.

Undifferentiated somatoform disorder - patients present with one or more physical complaints that persist beyond six months, are not due to a medical condition, and do not meet criteria for any of the other somatoform disorders.

Conversion disorder - patients present with one or more symptoms affecting voluntary motor or sensory function that suggest a neurologic condition but are thought to be initiated or exacerbated by psychological stress rather than a true neurologic process.

Pain disorder - patients present with pain in one or more anatomical sites that is sufficiently severe to warrant clinical attention and is judged to be precipitated or exaggerated by psychological factors.

Hypochondriasis - patients are preoccupied with the fear or idea of having a serious disease based on the misinterpretation of bodily symptoms or minor physical abnormalities, despite appropriate medical evaluation and reassurance.

Body dysmorphic disorder - patients are preoccupied with a physical defect in appearance which may be imagined; if a minor physical anomaly is present, patients display markedly excessive concern about the physical feature.

Somatoform disorder not otherwise specified - patients present with somatic complaints that do not meet criteria for the above somatoform disorders; an example includespseudocyesis, a false belief of being pregnant that is associated with objective signs of pregnancy.

Common to all of the somatoform disorders is the presence of symptoms that cause clinically significant distress and impairment in social, occupational or other important areas of functioning.

As with factitious disorders, patients who are admitted to the hospital for evaluation of symptoms that could be resulting from a somatoform disorder or malingering require a strategic approach to diagnosis and treatment.

II. Diagnosis

A. Differential diagnosis

Factitious disorder, malingering and somatoform disorders can present similarly, and as such, are often considered in the differential diagnosis together. When attempting to distinguish among these three categories, it is helpful to consider whether the symptoms are intentionally or unintentionally produced and what the motivation is for the illness.

For example, in somatoform disorders, symptoms are unintentionally produced and the motivation for illness is unconscious. In factitious disorders, there is intentional production of symptoms and unconscious motivation for illness. Lastly, in malingering, the patient intentionally creates symptoms and has a conscious motivation for illness.

Psychiatric conditions such as depression, delusional disorder, anxiety, schizophrenia, and substance abuse can result in similar presentations and therefore should be considered as alternative diagnoses. Additionally, caution must be used to ensure that there is not a true medical illness that is leading to or compounding the patient's complaints.

Since the presenting signs and symptoms of factitious illness can vary widely, the differential diagnosis must be considered on a case by case basis. For example, in a patient with factitious fever, any diagnosis which would normally be considered for fever of unknown origin should initially be on the differential. Alternatively, in a patient who is feigning hallucinations, a comprehensive list of medical, psychiatric and substance-related causes must be considered during evaluation.

Finally, factitious illness will not be diagnosed if the provider does not include it in the differential diagnosis. Likewise, malingering and somatoform disorders must be considered in order to make the diagnosis. Subsequent sections will highlight certain historical features and other clues that may increase suspicion for these conditions.

B. Diagnostic approach

All patients who report signs and symptoms significant enough to warrant hospitalization must be carefully evaluated. Diagnosis of factitious disorder can be exceedingly challenging and is often late in the course of illness, largely because the diagnosis was not initially considered. Perhaps the most important initial steps for hospitalists are to manage any immediate complications of the patient's presentation and to exclude life-threatening medical causes of the patient's clinical picture.

Regardless of whether the illness was consciously or unconsciously produced and independent of the motivation for becoming hospitalized, the provider's role is to care for the patient in a thoughtful and nonjudgmental way, and similar attention should be given to determining the underlying cause of illness. In the case of factitious disorder and malingering, direct evidence (e.g., catching the patient in the act of self-inflicting injury or manipulating laboratory samples) is often needed to confirm the diagnosis.

1. History

A thorough history is paramount when differentiating between true medical and psychiatric illnesses and those that may be factitious, somatoform or related to malingering. Aspects of the history that may be particularly important are the history of present illness, past medical history and social history. Specific elements of interest include:

History of present illness:

◦ time course of symptoms, particularly as they might relate to stressful events

◦ obtain collateral information from family members (with the patient's consent)

◦ be attentive for inconsistencies or gaps in the history

Past medical history:

◦ history of comorbid psychiatric illness

◦ history of prior hospitalization

◦ obtain outside hospital records and history from other providers (with the patient's consent)

Social history:

◦ social support and living situation

◦ work history and history of disability

◦ substance use

◦ past history of physical, emotional or sexual abuse

When obtaining a history from a patient suspected of a factitious illness, providers must be nonjudgmental and consider the possibility that genuine medical problems may co-exist. Regardless of whether a factitious or somatoform disorder is ultimately diagnosed, ascertaining these details may provide valuable insight into the patient's complaints and behaviors.

2. Physical examination

The physical exam in patients who are suspected of having a factitious or somatoform disorder or malingering can provide evidence to support or refute the diagnosis. As with any hospitalized patient, a full exam must be performed, with particular attention being given to objective findings that relate to the patient's presenting complaints. Given the variety of symptoms with which patients may present, there are no specific exam findings that are common to all patients with factitious illnesses.

Examples of potentially pertinent exam data include:

a "gridiron abdomen" of multiple surgical scars

motor or sensory deficits that do not correspond to a neurological distribution

seizure-like activity where the patient is fully oriented immediately following the episode

non-healing skin wounds that are only located in areas of the body that the patient can reach, such as the front of the body, and more lesions on the non-dominant side.

In factitious disorder, malingering, and somatoform disorders, the exam is most often notable for theabsence of findings to fully explain the patient's symptoms.

3. Laboratory and other testing

As with the history and physical examination, the value of laboratory testing will depend on the patient's presenting signs and symptoms. In some cases there are specific diagnostic tests that may be helpful to confirm the diagnosis.

For example, in a patient with non-healing wounds, a tissue biopsy might differentiate a naturally occurring skin lesion from a traumatic injury; in such cases, alerting the pathologist to the possibility of a self-inflicted lesion would be important. Alternatively, a serum insulin and C-peptide level would help to differentiate exogenous insulin injection from true hypoglycemia.

However, as a general rule, experts recommend that providers be conservative with the use of diagnostic testing in individuals suspected of factitious disorder. Patients with factitious illness tend to be unusually eager to undergo invasive procedures to perpetuate the sick role. Patients who are malingering, on the other hand, will often be resistant to invasive testing.

Lastly, observation of the patient's behaviors can be very effective in raising suspicion for and making a diagnosis of factitious disorder or malingering. Sometimes, as in the case of pseudoseizures, the sign or symptom will only occur in the presence of an audience.

Other times, such as with factitious hematemesis, the sign or symptom might never be witnessed, yet the patient continues to report the symptom and/or produce specimens. In yet other cases, in which the patient may be covertly ingesting or injecting a substance, direct evidence of self-injurious behavior may be necessary to confirm a diagnosis.

C. Clues and characteristics

Diagnosing factitious disorder, malingering and somatoform disorders can be difficult. The true diagnosis is often elusive for a number of reasons. First, because of the varied presentations, pattern recognition may not be reliable, and a high index of suspicion is necessary in order to make the diagnosis.

Additionally, because of the tendency for medical providers to believe their patients, the diagnosis may not be seriously considered. Next, because these patients often seek care at different hospitals, important clues may not be readily accessible. Furthermore, patients may have actual medical conditions which complicate the presentation.

There are a number of patient factors and behaviors which may increase the suspicion for a factitious disorder:

discrepancies between the history and objective findings

gaps or inconsistencies in the history

history of multiple admissions at different hospitals, often in different cities

knowledge of medical terminology and textbook descriptions of illness

employment in or exposure to a medically-related field

personal history of illness and hospitalization, often early in life

female sex

age 20-40 years

unusually calm acceptance of the risks and discomfort of diagnostic procedures or surgical treatments

development of new or evolving symptoms when the work-up returns negative

Patients with chronic factitious disorder, Munchausen syndrome, differ in that they are more likely to be male and to exhibit antisocial tendencies. Typically they will have a history of recurrent hospitalization and frequent traveling. Patients with Munchausen syndrome often tell elaborate stories of their illness, which is referred to as pseudologia fantastica. Additionally, when confronted, these patients are more likely to demonstrate hostile behavior and demand discharge against medical advice.

Factitious disorder by proxy, a condition in which a caregiver intentionally produces illness in one of his or her dependents, is most commonly encountered in the pediatric setting, typically involving a mother causing illness in her child for her own need to play the sick role. These individuals present with the outward appearance of being caring and concerned, but are in fact highly manipulative, and when they are not being observed, show little attention to the proxy.

As with factitious disorder, perpetrators are more likely than the general population to have a history of personality disorder, childhood neglect or trauma, comorbid psychiatric illness, and connection to the healthcare field. Of note, factitious disorder by proxy has also been described in the geriatric population, where elders are the target of the falsified illness, which is usually produced by their adult children who are serving as caregivers.

Malingering should be suspected in patients who have an apparent secondary gain. There is usually an obvious incentive, such as avoiding criminal prosecution, supporting personal injury claims, or securing food and shelter, though varying motivations have been described. Suspicion may be raised when inconsistencies within the history, or between the symptoms and objective findings, are apparent.

Additionally, patients will behave differently when they think they are being observed. Criminal defendents who malinger commonly simulate mental rather than physical illness, presenting with claims of psychosis or memory impairment. Individuals who malinger are also more likely to have antisocial personality disorder. Importantly, "successful" malingerers present in a less extreme fashion, complaining of fewer symptoms, often clustered in a more believable way. In most circumstances, patients who are malingering clinically improve once the incentive for being hospitalized is gone.

Somatoform disorders, like factitious disorder, vary widely in presentation, and may be even more difficult to diagnose because the production of illness is unconscious. Conversion disorder, pain disorder, and hypochondriasis are certainly encountered in the hospital setting. Many of the same patient factors apply, including female sex and a history of stressful early life events, as well as comorbid personality disorders and anxiety. Somatoform disorders tend to be chronic and characterized by significant functional and social impairment, and as a result, a history of "doctor-shopping" may be evident.

D. Over-utilized or “wasted” diagnostic tests

As above, patients with factitious disorder are typically very willing to undergo diagnostic testing, particularly invasive procedures. Experts recommend a conservative approach to diagnostic testing in this patient population. History, physical examination, gathering of outside records, and observation of the patient's behaviors are often sufficient to arrive at the diagnosis.

III. Management

A. Treatment approach

Medical and surgical treatments should be provided as needed to treat comorbidities and complications resulting from factitious disorder, malingering, and somatoform disorders. Treatment should also be focused on the goals of preventing further self-injury and diminishing the risk of iatrogenic complications that might occur during hospitalization. This can be achieved by close monitoring of the patient and by minimizing invasive procedures.

When a factitious illness is suspected, psychiatric consultation should be sought. By engaging psychiatry early, the medical team can obtain guidance regarding the patient's evaluation, confirmation of the diagnosis, addressing the patient, initiating treatment, and monitoring. Importantly, the psychiatry team can also provide support and education for the patient's family and the medical staff caring for the patient, all of whom may be coping with their own feelings of disbelief, anger, guilt, or other emotions.

The patient should be confronted with the team's suspicions; confrontation must be done in a gentle and non-judgmental manner, focusing on the evidence and the underlying distress leading to the individual's behavior, rather than the behavior itself. Clinicians should not set an expectation that the patient confess or acknowledge the deception.

Typically, patients with factitious disorder will deny that they have feigned their illness, and frequently they will become hostile or even leave the hospital against medical advice. Nonetheless, psychiatric care and support should be offered. Patients will often try to split the team, so it is critical that all health care providers collaborate to send a consistent message.

Psychiatric care is the cornerstone of management of factitious disorder. Involuntary hospitalization is only indicated when the patient poses an immediate, serious threat to himself. However, the inpatient medical hospitalization presents an opportunity to confirm the diagnosis and introduce the concepts and goals of psychiatric care. As factitious disorder is a chronic disease, much of the treatment will be provided on an outpatient basis. Psychotherapy and cognitive behavioral therapy may provide some benefit. Pharmacotherapy does not play a signficant role in treatment, except for treating comorbid depression, anxiety, or other axis I diagnoses.

When factitious disorder by proxy is suspected, the authorities should be notified. Since the abusive behavior enacted on the proxy is considered a crime, the urgency of diagnosis and treatment is that much greater. Initial interventions should be focused on ensuring the safety of the victim, such as by involving child protection services and removing the child from the home.

Additionally, the entire family situation should be assessed. Treatment of the perpetrator is similar to that of other factitious disorders, with psychotherapy aimed at helping the individual express needs for recognition more directly. Pharmacotherapy is only indicated for the treatment of comorbid psychiatric diagnoses.

Since malingering is technically not a psychiatric diagnosis, management tends to be rooted in an understanding of the secondary gains associated with the production of symptoms, rather than psychiatric treatment of the individual. Interventions should be designed to reduce the motivation to malinger, and may include educational and family support as well as cognitive behavioral techniques. Patients will usually stop feigning illness when the motivations for malingering have been removed.

Somatoform disorders can also be very difficult to treat, as they tend to be chronic, with waxing and waning symptoms. In these cases providers should emphasize functionality and coping skills, and focus on management of symptoms rather than cure. However, pyschotherapy and pharmacotherapy, specifically antidepressants such as selective serotonin reuptake inhibitors, may be beneficial. Cognitive behavioral therapy has also been shown to be effective.

B. Common pitfalls

The diagnosis and management of factitious disorder, malingering, and somatoform disorder can present medicolegal and ethical dilemmas for providers. First, physicians are taught to believe their patients, so when the diagnosis is suspected, and certainly when it is confirmed, physicians and other members of the medical team can experience a variety of emotions, such as anger and frustration.

This is compounded by the fact that these patients, with their comorbid axis I and II disorders and demand for attention, can be very difficult to manage even in the absence of an acute feigned illness. Additionally, the need to procure evidence must be balanced with the patient's right to privacy and autonomy.

Furthermore, especially in the cases of factitious disorder by proxy and malingering, the stakes are high, as these diagnoses could have devastating consequences if missed, but false-positive diagnoses must be avoided as well. These situations are further complicated by the involvement of the authorities, which can turn a medical presentation into a legal case.

Experts do have some specific recommendations regarding the management of these patients.

Approaches to avoid

Don't notify other hospitals of the patient's admission

Don't search a patient's belongings without his or her consent

Don't tape a patient without his or her consent, unless surveillance monitoring is a routine aspect of care

Don't exclude the possibility of co-existing true medical or psychiatric disorder, even if factitious illness or malingering are diagnosed

Don't abandon the patient

Don't let the patient dictate which tests to perform or not perform

Don't expect or insist that the patient confess to deception

Recommended approaches

Do involve psychiatry consultants as soon as factitious disorder is suspected

Do offer psychotherapy, though acknowledge that it will not be helpful if the patient isn't receptive

Do establish trust and communicate that the team will continue to provide care for the patient

Do be mindful of countertransference and biases such as early closure

Do work as a cohesive team and convey consistent messages to the patient, who will frequently try to split the team

Do encourage the patient to establish a relationship with a single provider/center

Do evaluate and treat coexisting medical and psychiatric disease and substance abuse